Winning Trust, Minimizing IT Resources: Key to Forming

RHIOs

Mark Singh MD, President, Clinicore Kathleen Sullivan MPH, CEO, Salient Health

The SEMRHIO Experience

Introduction

• Hospitals: Greater demand for electronic data delivery: EMRs interfaces, Portals

• Physicians: Clinical data from multiple disparate sources

• RHIOs: a solution – Significant Barriers: Trust/Security, Cost

• Hospital buy-in: Need to overcome these barriers

Our Experience in forming SEMRHIO• South Eastern Massachusetts Regional Healthcare

Information Organization

Milton Hospital

Jordan Hospital

Quincy Medical Center

Overcoming Barriers

• Developed a model: – Gain Trust– Minimize Hospital IT infrastructure

• lower cost of entry

• Won Approval from Hospital Leadership– SEMRHIO

Problems Addressed• Need to support EMR adoption, electronic data

delivery, interfaces to hospital systems– Immediate problem which needs a solution within

next 2-3 years• Health care delivery is distributed through out

community– Challenge to have the appropriate data available in

order to provide safe patient care– Trying to keep; up with fax machines: tough

EMR Adoption

• More doctors implementing EMRs• Hospitals being asked to provide

interfaces – Need to serve small and large practices– Can this this be done more efficiently by

hospitals as a “group”: RHIO?

Care Delivered at Multiple Sites

Doctor’s offices

HospitalImaging Center Surgi-center

Labs

Patient

Clinical Data is spread out

• When taking care of a patient, need to have access to data from all the other sites– Care delivered in Physician's offices (multiple

specialists, PCP)– Hospitals/Emergency Rooms– Nursing Homes

Need to Solve:

• How do we deliver clinical data electronically?

• How to consolidate clinical data set in real from disparate healthcare entities in order to care for patients?

Solving these Problems

• RHIO seems to makes sense:– multi-stakeholder organization – Allow shared costs of common IT

infrastructure• Economies of scale

– Framework for data sharing among competing organizations

RHIO: Challenges and Barriers

• Perceived Negatives regarding RHIOs– Too costly, Lack of sustainability models– Too many security and trust issues among

Competing entities. • uncomfortable with concept of “Sharing” clinical

data

“California RHIO closes amid cost, privacy concerns”

eHealth SmartBrief | 07/11/2007

The closure of the Santa Barbara Co. Care Data Exchange

Given these significant barriers, how do we get community based, independent, competing hospitals to form a RHIO?

Need to Address Potential Barriers

• Cost and Security issues:

– Lack of IT Infrastructure and Resources• Hospitals have more immediate pressing issues:

– i.e., CPOE , eMAR

– Trust among disparate organizations

Trust in Forming a RHIO

• Issue of Architecture, business process– When thinking about RHIOs, we consider

classic approach for RHIO architectures– Classic Model is a “federated”, “Pull” based

architecture using a Record Locator Service (RLS)

“PULL” based Model

H

Hospital-A

1

Patienthas CAD,

CHF.

DrugAddiction

Hx

Sodium135,

Cholesterol 187,

Glucose

Pull Based RHIO ModelReturn only permitted data

RLS

Hospital-B

Patienthas CAD,CHF. Aso

HIV.Patient

hasNausea Asoh/o HIV.

Patienthas CAD,

CHF.AIDS

Hospital-C

MentalHealth Hx

2

3

User requests recordson patient

User not entitled to receive datacontaining mental health, HIV,substance abuse information

Get John Doe’s dataSearch for John

Doe’s data across hospitals

Return data but exclude: data with “HIV”, “Substance

Abuse”, “Mental Health”

Pull ModelComplicates Trust issues

• Pull may work very well in a multi-site, single- organization

• Has problems in a multi-organizational setting- Problematic

– Introduces new Trust issues– Each hospital (source) needs to determine what data

each user can access– Model opens up a “can of worms”– Can be a “show stopper” in forming RHIOs

“Best to automate an existing business process and trust

relationship” “The RHIO experience in Massachusetts” John Halamka D. MD, CEO MA-SHARE

May 4, 2007

How do we build Trust ?

Use an existing Trust relationship Use an existing Business Process

Existing Business Process and Trust Relationship

“PUSH” model

The directed delivery of clinical data from to provider

Healthcare entityPush

PUSH Model for Exchange

Patienthas CAD,CHF. Aso

h.

Had h/ofall. Feltdizzine

ss.

Patienthas CAD,CHF. Asoh/o HIV.

Patienthas CAD,CHF. Asoh/o HIV.

PatienthasNausea Asoh/o HIV.

Sodium135,

Cholesterol 187,

Glucose130

PUSH Based HealthInformation Interchange

PUSH toAuthorizedRecipient

Sodium135,

Cholesterol 187,

Glucose130

Sodium135,

Cholesterol 187,

Glucose130

Sodium135,

Cholesterol 187,

Glucose130

InBox

Building Trust: "push" model—A doctor or healthcare entity decides what data to send to another doctor or entity.

Proposed Model• Adopt conservative approach: Don’t change the

current arrangement– Hospital to send data to the legal recipient (“ordering”,

“primary” doctors) via RHIO (instead of fax/mail)• Once received by doctor, ownership of data

goes to doctor• Data sharing among doctors: “…for treatment,

payment, and healthcare operations” per HIPAA guidelines.

Local RHIO Data

Exchange

Dr Good

Dr Health

Dr Livelong

Dr Luck

Hospital A

Hospital B

Hospital C

Mega EMR

Mega Medical Group

STATE WIDE RHIO

Hospitals Exchange

Confidential Data via secure RHIO

Doctors can exchange reports securely with consulting and primary care physicians

Local RHIO connects to State

RHIO

Confidential Clinical Data Exchange via Local RHIO which reflects the local culture, physician relationships

SEMRHIO Security Model

Doctors have their own secure account for data sent to them by the hospitals

Doctor may only share data with another doctor for “Treatment and payment” per HIPAA guidelines

IT Infrastructure Issues• Hospitals wanted to commit minimal

resources• Major Component of the RHIO: Hospital

Information System (HIS) Integration– Need for HL7 Interface Engine– Involved increased cost and complexity

Onsite Integration

HL7 Engine

Integration Engine

Onsite setup and maintenance required

Specialized staff to manage interface

HL7

HL71

HL7 Engine

HL7 Engine

RHIO Software

HL7

HL72

HL73

HL7c

$

$

$

Is there an easier solution?

– Studied other possibilities• Extract desired data in near-real time, delimited

text format, using HIS query /reporting utility• Proposed Model:

– Local: Extract hospital data using existing the HIS query/reporting utility

– Central: Conversion to HL7 centrally using BizTalk.

Hosted Integration

BizTalk based

Integration

Engine

“Zero” local foot-print

HL7

Flat file

RHIO Software

Flat file

Flat file

$

Move HL7 integration infrastructure centrally

Advantages of Hosted Services Model

• Move infrastructure to the other side of the “Cloud”. – Simplify/minimize onsite infrastructure– Existing Local IT staff able to manage onsite

needs without additional training needed– Centralize interface management– Allow hospitals to share in economies of scale

Hosted Services

• Evolving Model: SOA ,SaaS• Trend towards Hosted services

– i.e., Salesforce.com, Google, Postini– Hosted email– Many Hospitals outsource their IT

infrastructure and support: e.g., Perot systems

Hosted Integration

• Minimizing IT resources• There was also a desire by hospitals to commit

minimal resources • Reluctance to install additional software/hardware locally. • We studied the existing hospital IT infrastructure and

developed a centralized “Hosted-Integration” model using BizTalk server.

• This was a “zero” local foot print implementation model which did not require any additional software/hardware locally, and was implemented using basic IT personal.

The Process

• Extract data from HIS use existing built-in reporting/query utility

• Hosted BizTalk integration server– BizTalk receive data at input ports– Delimited data mapped to HL7 2.x,

• The disparate data is mapped to a standard terminology. • Final data is stored in SQL 2005 for delivery to the

recipient physicians.

Source Lab data: Flat file ~delimited convert to HL7 v2x-XML

• 12222 ~01364999 ~000-00-0000 ~Doe,John ~11/30/39~67 ~F~3N ~367 ~ADM IN ~00966001~LITTLE ~RICHARD ~LITTLE,RICHARD M.D. ~1204:C00078R ~SODIUM ~T~BASIC METABOLIC PANEL ~CPT 4 ~84295 ~12/04/06~0717~12/04/06~0818~COMP ~136 ~135-145 ~mmol/L ~ ~

• 12222 ~01364999 ~ 000-00-0000 ~Doe,John ~11/30/39~67 ~F~3N ~367 ~ADM IN ~00966001~LITTLE ~RICHARD ~LITTLE,RICHARD M.D. ~1204:C00078R ~POTASSIUM ~T~BASIC METABOLIC PANEL ~CPT 4 ~84132 ~12/04/06~0717~12/04/06~0818~COMP ~4.2 ~3.7-5.2 ~mmol/L ~ ~

• <ns1:ORU_R01_231_GLO_DEF xmlns:ns2="AM.HL7.Schemas.Tables" xmlns:ns0="AM.HL7.Schemas.Segments" xmlns:ns1="AM.HL7.Schemas" xmlns:ns3="AM.HL7.Schemas.DataTypes">

• - <Sequence>• - <PID_PatientIdentificationSegment>• - <PID.2_PatientId>

– <CX.0_Id>064166</CX.0_Id> • </PID.2_PatientId>• - <PID.3_PatientIdentifierList>•

<CX.4_IdentifierTypeCode>MR</CX.4_IdentifierTypeCode >

• </PID.3_PatientIdentifierList>• - <PID.3_PatientIdentifierList>•

<CX.4_IdentifierTypeCode>MR</CX.4_Identifi erTypeCode>

• </PID.3_PatientIdentifierList>• - <PID.3_PatientIdentifierList>• <CX.0_Id>000-00-0000</CX.0_Id> •

<CX.4_IdentifierTypeCode>MR</CX.4_Identifi erTypeCode>

• </PID.3_PatientIdentifierList>• - <PID.5_PatientName>• - <XPN.0_FamilyLastName>•

<XPN.0.0_FamilyName>Doe</XPN.0.0_Family Name>

• </XPN.0_FamilyLastName>•

<XPN.1_GivenName>John</XPN.1_GivenNa me>

• </PID.5_PatientName>• <PID.7_DateTimeOfBirth>20331122</PID.7_DateTimeOf

Birth> • <PID.8_Sex>F</PID.8_Sex> • - <PID.18_PatientAccountNumber>• <CX.0_Id>49717259</CX.0_Id>

</PID 18 PatientAccountNumber>

Map FF to HL7 xml

Mapping Flat file to HL7 2x

BizTalk Orchestration

Clinical Results Viewer

An “EMR-Lite” client application to view the data was built using .NET and Microsoft’s “Composite Application Block”.

• Labs

• Radiology

• Clinical Reports

Clinical Events Viewer

Keeps track of patient events:-Hospital, ER

admissionsdischarges

- Bed Census

Conclusion:

• By using a “push” model and a BizTalk based “Hosted-Integration-Services” model:– Able to gain trust and minimize hospital IT resources

• Demonstrated how:– competing community hospitals can succeed in

winning approval for forming a RHIO by their hospital leadership.

Microsoft Technologies used:

– BizTalk 2006– Visual Studio 2005– SQL 2005– Composite Application Block

Technical TeamHospital• Mike Cosgrave• Brian Allen• Anne Baker• Jean Fernandez• Crowley, Sheryl

IT Infrastructure• Ed Powers, GlobalNet Solutions

– www.globalnetsolutions.com

BizTalkEric Stott, Information Architect, Clinicorehttp://blog.hl7-info.com/ http://blog.biztalk-info.com

Thanks!

For more information:Mark Singh MD

msingh at semrhio dot org